Acute Gastric enteritis, Diarrhea in children

1. Diarrheal Disorders in
Children
By Dr. K. FISEKO

2. DEFINITION**
• Acute Diarrhea is the passage of loose or watery stools, 3
times or more in 24 hour period for up to 14 days
• Or single motion containing blood.
• In the breastfed infant, the diagnosis is based on a change
in usual stool frequency and consistency as reported by the
mother

3. Classification of diarrhea
• Acute Diarrhea
• Starts acutely,
• Watery without visible blood,
• Last less than 14 days.
• (Desentry is acute diarrhea with visible blood in stool)
• Persistent diarrhea
• Started as acute diarrhea (watery or desentry) but persist more
than 14 days.

4. • Chronic diarrhea
• Diarrhea of gradual onset, lasting greater or equal to 1 month
or recurrent due to non infectious cause
• Stool output is more than 10g /kg/day

5. Mechanisms of diarrhea
•Osmotic
•Secretory
•Exudation
•Abnormal motility

6. Acute non infective diarrhea
• Diet
• Over feeding
• Under feeding: Starvation diarrhea (scanty, greenish, excessive
mucus)
• Bad feeding:
• Change in milk type or concentration
• New unsuitable food.
• Lienteric diarrhea: Hyperactive gastro-colic reflex -+ motion short
after every feed

7. • Drugs
• Parenteral diarrhea (better called 2ry gastroenteritis).
• Due to infections outside GIT e.g. otitis media, respiratory
infections, urinary tract infections
• Possible mechanisms: -toxic absorption and reflex gastro
intestinal irritation
• The term parenteral diarrhea is no longer used due to
possible associated intestinal infection.

8. Acute Infective diarrhea (Gastro
Enteritis)
• Gastro-enteritis involve enteritis & reflex gastritis ~
vomiting & diarrhea.

9. CAUSES AND RISK FACTORS FOR ACUTE
DIARRHOEA
• Microbial
• Host
• Environmental
factors interact to cause Acute Gastroenteritis

10. HOST FACTORS
• BIOLOGICAL FACTORS
• Malnutrition
• Age
• Failure to get immunized against rotavirus
• HIV
• BEHAVIORAL FACTORS
• Not breastfeeding exclusively for 6 months
• Using infant feeding bottles
• Poor hygiene

11. ENVIRONMENTAL FACTORS
• Seasons
• Poor domestic and environmental sanitation especially
unsafe water
• Poverty

12. MICROBIAL FACTORS
• VIRAL
• Rotavirus
• Adenovirus
• Norwalk virus
• Astrovirus
• CMV
• BACTERIAL
• Vibrio cholerae O1
• Salmonalla spp
• Shigella
• E. coli 0157:7
• Campylobacter pylori

13. • PARASITIC
• Gardia lamblia
• Entamoeba histolytica
• Cryptosporidium

14. • FUNGI
• Candida albicans.
• PARENTERAL CAUSES: Pneumonia, pyelonephritis,
septicemia and malaria.
• DIETARY & OTHERS: food allergy e.g cows milk,
drugs e.g Ampicillin.

16. • HISTORY
• Onset, duration, number of stools per day, wet nappies
• Blood in stools
• Feeds
• Episodes of vomiting
• Presence of fever, convulsions etc
• Type and amounts of fluids taken
• History of travel
• Drug history
• Immunisation history

17. Complications of Gastroenteritis
• Dehydration
• Shock
• AKI
• Metabolic Acidosis
• Electrolyte disturbance
• Convulsions
• CNS infections: meningitis & encephalitis due to shigella
or neurotropic virus
• Persistent diarrhea
• Malnutrition

18. ASSESSMENT
• GOALS
• Identify the type of diarrhea
• Look for dehydration
• grade if present
• Vitals
• other complications
• Assess for malnutrition (anthropometery)
• Rule out non-diarrheal illnesses
• Assess feeding

19. Infants are more susceptible to
dehydration than adults, why?
• Relative excess of total body water.
• Higher daily requirements of water in infants (ISO ml
/kg/d)
• Higher frequency of diarrheal diseases in infants &
children
• Smaller metabolic reserve of water and electrolytes
• Limited power of the kidneys to concentrate urine

20. Degrees of Dehydration
• According to degree of body weight loss
• Mild < 5%
• Moderate 5-10%
• Severe > 10%
• Loss of> 15% of body weight due to dehydration is
incompatible with life!!!
• Laboratory
• From degree of rise of hematocrit ,hemoglobin, urea, plasma
proteins.

21. According to WHO plans

24. INVESTIGATIONS
• Stool Investigation
• Physical
• Microscopy. Culture and sensitivity
• virology
• Urea and Electrolytes
• FBC

25. MANAGEMENT
• Principles:
• Rehydration and maintaining hydration
• Ensure adequate feeding
• Oral supplementation of zinc
• Early recognition of danger signs and treatment of
complications

26. HYDRATE HYDRATE HYDRATE
HYDRATE HYDRATE!!!!!!!!!!!!

27. PLAN A
• May be treated at home.
• Danger signs to be explained to mother
• Diarrhea continues >3days
• Increased stool volume/frequency
• Repeated vomiting
• Increasing thirst
• Increased irritability/lethargy
• Refusal to feed
• Fever or blood in stool

28. AGE yrs <2 2-5 Older
children
ORS(mls) 50-100 100-200 As much as
they want

29. • Zinc supplement
• 10-20mg (2.5ml-5ml)/day for 10-14days
• Important oxidant and preserves cellular membrane
integrity
• Promotes growth and development of the nervous
system

30. PLAN B
• Treated in hospital
• 75mls/kg of ORS to be given in 4hrs, if not taken orally
then NGT can be used
• If after 4hrs child still has some dehydration, again
75mls/kg of ORS to be given.
• Ineffective in:
• High stool purge
• Persistent vomiting
• Paralytic ileus
• Incorrect preparation of ORS

31. • When signs of dehydration disappears, ORS should be
administered in volumes equal to diarrheal losses (max
10ml/kg)
• Breastfeeding, semi-solid foods continued after deficit
replacement.

32. PLAN C
• Treated in hospital
• Ideal fluid is RL with 5% dextrose or ½ strength Darrows, NS or RL can be
used as alternative. NO 5% dextrose should be used.
• Total 100ml/kg should be given
• If severe dehydration is persistent repeat IV fluids
• Hydration improved but some dehydration present, sift to plan B
• If no dehydration shift to plan A
• Reassess patient every 15 to 30 min for pulses and hydration status
AGE 30ml/kg 70ml/kg
<1 year 1hr 5hr
>1 year 30 min 2hrs 30min

33. • Antimotility agents (loperamide) are
CONTRAINDICATED
• Antibiotic therapy in select cases of diarrhea related to
bacterial infections can reduce the duration and severity of
illness and prevent complications
• their widespread and indiscriminate use = antimicrobial
resistance.

34. Oral rehydration solution (ORS)
• Mechanism of ORS ~ co absorption of Na & glucose or
certain amino acids even via damaged intestinal mucosa ~
other electrolytes esp. chloride are absorbed 2ry to Na.
• WHO ORS (2005) --dissolved in l liter

35. Other types of ORS:
• ReSoMal
• ORS containing less sodium more potassium with added
magnesium, copper & zinc.
• Mainly for rehydration of severely malnourished infants
• Lohydran
• with low Na cl (Na = 65 m.mol/1, c1 = 55 m.mol/1)
• used for: infants < 6 months & hypernatremic dehydration.

36. Advantage of ORS Limitations of ORS.
fit for Not fit for
1. All types of dehydration 1. Shocked cases
2. Any age even the newborn 2. If IV fluids is indicated
3. Any type of diarrhea 3. Glucose Malabsorption
(rare) i.e. ORS will not be
absorbed = osmotic diarrhea
will occur
4. Associated fever, acidosis
or vomiting are not
contraindications
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37. THANK YOU!!!!

38. SENARIO
• A 13 month old child had a 3 day history of green watery stools.
She has also been vomiting for 1 day.
• Physical exam reveals a febrile, irritable baby with dry mucous
membranes and sunken eyes.
• WHAT IS YOUR DIAGNOSIS
• OUTLINE YOUR TREATMENT PLAN